Vape the smoke away: A case for e-cigarette based Tobacco Harm Reduction

Smoking rates have been decreasing slowly and minimally over recent years. Hereby, smokers keep exposing themselves to one of the leading causes of years of potential life lost. Current smoking cessation aids and strategies appear to be insufficient to further reduce smoking rates substantially and rapidly. Contributing factors to these disappointing figures are: 1) the fact that current aids do not take into account the behavioral aspects of smoking and do not deliver sufficient nicotine to the user, 2) the idea that nicotine concentrations need to be reduced quickly to zero, and 3) the assumption that the main aim should be to completely quit using any form of nicotine/tobacco, which may not be attainable, nor even be desirable for many smokers. In contrast, Tobacco Harm Reduction (THR) focusses on reducing or ideally eliminating the harmful effects of smoking tobacco by providing smokers with low(er)-risk alternatives. THR will be the focus of this dissertation and two promising THR candidates will be investigated: electronic cigarettes (e-cigarettes) and Heat-not-Burn (HnB) cigarettes. The majority of the presented studies will target the e-cigarette. Chapter 1 describes our first randomized controlled trial wherein smokers, with no intention to quit smoking, were provided with (at that time being up-to-date) second-generation e-cigarettes. The trial investigated the acute effects of using e-cigarettes on craving reduction, and the long-term effects on smoking abstinence/reduction and experienced benefits/complaints. A total of 21% of participants was completely smoking abstinent six months after the final lab session. Chapter 2 consists of two studies aiming at implementing the e-cigarette in the standard smoking cessation treatment by tobacco counselors. The first study was a prospective cohort study showing that e-cigarette users had higher chances to be smoking abstinent compared to NRT (nicotine replacement therapy) users. The small sample size and short follow-up period of this study were countered in a second, larger interventional cohort study with seven months follow-up. Around 40% of e-cigarette users was completely smoking abstinent at the end, compared to 20% of NRT users. Chapter 3 comprises a six-month longitudinal field study focusing on smokers who were novice to vaping. We investigated the smoking/vaping trajectories and quit-smoking rates of smokers buying their first e-cigarette in a vape shop. Results revealed that almost 20% was smoking abstinent at the end of the study period. The last chapter regarding e-cigarettes, Chapter 4, focuses on dual users of both e-cigarettes and tobacco cigarettes. The study used an online questionnaire to determine potential differences between dual users and exclusive e-cigarette users. Main differences centered around variables proximal to the vaping behavior and its experienced effects. The final part of the dissertation will zoom into HnB cigarettes. Chapter 5 presents a randomized crossover behavioral trial that compared the acute effects on cigarette craving of using a HnB cigarette with using an e-cigarette or a tobacco cigarette. Overall, the HnB cigarette was equally effective as an e-cigarette and tobacco cigarette, with HnB cigarettes being slightly preferred over the e-cigarette. Finally, in Chapter 6 this dissertation provides an overall conclusion of the presented studies and will try to provide answers on the current challenges within the THR research field. The main conclusion is that it is important to provide smokers with a range of THR aids in addition to the currently available smoking cessation aids.

Publication year:2020

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